In Convergence Model, Coordinated Patient Engagement is Key

There were many points of disagreement among healthcare executives, clinical leaders, and clinicians in the recent New England Journal of Medicine (NEJM) Catalyst Insights Council’s survey on patient engagement. Most centered on the effectiveness of solutions ranging from texting apps to clinical wearables, with the executives who buy the solutions more confident than the clinicians who actually use them. As one clinician said in the survey’s open-response section, in the last two decades, “other than the glucometer and home blood pressure cuff, nothing useful has materialized.”

However, there was one point of alignment: Healthcare providers expect payers to foot the bill for engagement tech.

In traditional fee-for-service (FFS) healthcare, this is a great way to thwart a patient engagement initiative before it can even start. As our upcoming report on prior authorization notes, payers and providers have different reasons for engaging with patients – broadly, steerage and utilization management for the former, retention and satisfaction for the latter. Assuming that someone else will do exactly what you want, when their business model actually requires them to do something completely different, won’t get you very far.

Take chronic condition management. A recent report (PDF) from West Corp. suggests that patients don’t know how to manage their conditions, by and large, while physicians aren’t communicating to patients which health metrics to target when managing their conditions. The negative implications are all too clear: The onset of comorbidities as a result of poorly managed symptoms, more frequent high-acuity care episodes, higher costs, and a damning impact on personal health, well-being, and quality of life.

In value-based care (VBC) – where the interests of payers and providers converge – a model where payers pay for the solutions that providers use to engage with patients actually presents an opportunity. This is especially true since many VBC models to date, namely accountable care organizations, have targeted populations of high-cost Medicare beneficiaries with multiple comorbidities.

• With direct insight into what services cost, a payer can quantify the ROI of an investment in an engagement solution under a risk-based contract and bake this cost into the contract.
• A provider can identify the solutions that best align with clinical best practices for chronic condition management. (This addresses another challenge identified in the NEJM survey: That providers don’t know what programs to recommend to patients and, therefore, don’t bother.)
• A combination of clinical and claims data can identify and risk-stratify patients for program enrollment, noting not just the need for intervention but also the likelihood of ongoing response.
• A coordinated engagement effort between payer and provider can offer a “single version of the truth” to patients, one bereft of conflicting care plans, treatment recommendations, or prescriptions.
• Coordination can increase adherence with care plans, which lowers overall care costs, generates savings under a VBC model, and improves clinical and non-clinical outcomes.

Yes, this list represents an ideal scenario. It requires payers, providers, and patients to cooperate in new, different, and at times uncomfortable ways. It requires an approach that shifts from chastising non-compliant patients to working with patients to identify and overcome barriers ranging from low health literacy to an inability to afford copays. It requires changes to clinical workflows, staffing models, and longstanding beliefs about how healthcare in the United States must work. Above all, it requires admitting that the status quo is unaffordable, untenable, and unstainable.

That said, no VBC model or convergence initiative will succeed unless patients are engaged – and not through lip-service methodologies such as outdated portals, impersonal emails, or robo-call voicemails. Coordinated patient engagement efforts are necessary to achieve the financial and clinical outcomes that VBC requires, that convergence promises, and that patients demand.